Pediatric Anesthesia Guidelines

Pediatric Anesthesia

• Precordial stethoscope and SPO2 are required for induction
• EKG and NIBP can wait until after induction
• Appropriate sized ambu bag and circuit
• IV kit = 20, 22, 24 angiocaths
• IV fluids = 4/2/1
• Preop IV = Mr. Freeze, EMLA kit
• Average weight in kg = age in years x 2 + 10 = 90th percentile
• Emergency medications: atropine (0.2 mg/kg), succinylcholine (2 mg/kg IV; 4 mg/kg IM), epi (10mcg/kg)
• Preop evaluation: length of pregnancy, hx of IVH/assisted ventilation, family hx of anesthesia problems, sickle cell or trait, GERD, recent colds/URI
• NPO guidelines: clear liquid 2 hours, breast milk 4 hours, formula 6 hours, solids 8 hours
• Premedication: Can make emergence slow. IM, IN, PO ketamine, fentanyl, versed
• Induction: Inhalation (N2O 70%, O2 30%), consider stun dose prior to sevo, IV or combined
• Benefit of spontaneous ventilation on inhalation agent = autoregulation
• Too deep - pt will breathe slower and take in less volatile
• Too light - pt will breathe quicker and take in more volatile.
• Bronchospasm causes = RAD, mainstem ETT, mechanical obstruction (e.g., kinked ETT)

Pediatric Emergencies

• Symptoms of difficulty or inability to ventilate include high peak pressures, desaturation, and low or no ETCO2, no breath sounds, and minimal chest rise.
• Treatments include 100% FiO2, deepening anesthetic, beta agonists, epi, terbutaline, ketamine, aminophylline, lidocaine, corticosteroid.
• Risks of Emergence delirium.
• Risk of induction with sevo but consider changing to another volatile, desflurane tends to keep HR higher - good in kids because CO depends on HR

Pediatric Regional Techniques

• Caudal
• TAPS common for umbilical hernia repairs
• Maintenance fluid in 4/2/1
• 10 kg child with minimal insensible fluid losses= 40, 40, and 40

Pediatric Stimulation/Extubation

• Consider SIMV mode
• Ensure pt is out of stage 2
• Suction
• Pull ETT with positive pressure
• Immediately apply mask with positive pressure and jaw thrust until adequate respiration is noted
• Deep extubation: suction, consider oral airway, pull ETT and provide jaw thrust with positive pressure, turn off gas and support the airway, signs of stage 2(thrashing, red sclera, dysconjugate gaze)
• Resolution of stage 2 ( return of normal gaze), white sclera, gumming ETT
• Swallowing (grimace, tear formation)
• Laryngospasm - forceful involuntary spasm of the laryngeal musculature. Cause by upper airway restriction, secretions or light anesthesia. Solutions: 100% FiO2, positive pressure (<20 cmH2O), jaw thrust, succinylcholine
• Post-extubation stridor, Causes = high cuff pressures, airway swelling, ETT movement in trachea, treatment = humidified O2, steroids, racemic epi.

Common Pediatric Surgeries

• Rules for pediatric surgery: preparation, open communication, teamwork, backup
• BMT = bilateral myringotomy with tubes
• Tonsillectomy and adenoidectomy (T&A).
• Excision of palatine tonsils and adenoids.
• Position supine with arms at sides and bed turned 90 degrees
• Used with oral RAE tube.
• Maintainence: low O2, IVF, antiemetics, empty stomach
• Transport pts to PACU in lateral position with blow by oxygen, If re-bleeding happens, consider the patient a full stomach.
• Inguinal hernia repair, position supine, arms at sides, caudal block.
• Umbilical hernia repair (Population >3 YO), TAPS block
• Pyloromyotomy

Other Pediatric Considerations

• Hypertrophy of muscle fibers of the pyloric sphincter can cause gastric outlet obstruction (olive-shaped mass).
• Not a surgical emergency, but medical, requiring fluid and electrolyte balance correction.
• Dehydrated hyperchloremic metabolic alkalosis from vomiting
• Compensatory hypoventilation to increase CO2
• High pH suppresses the central respiratory centers leading to inappropriate respiratory response
• Patient population = usually several weeks old
• Positioning: supine, pt may be turned 90 degrees away.
• Broviac/Mediport = Frequent or long term IV access, done with fluoroscopy, similar to central line placement.
• Maintenance: Not very painful so ½ dose of narcotic is usually sufficient, ectopy while threading the catheter
• Special considerations: sickle cell (need warm room, cold causes sickling), cancer (family interaction, immunocompromised), adjuncts/procedures (bone marrow biopsy, LP)

Other Procedures

• Circumcision: Usually done a day or two after birth. Simplest anesthetic technique is the subcutaneous ring block (using LA with NO EPI) at the base of the penis, no epi in LA used for fingers, toes, or nose
• Complications include hematoma and penis ischemia
• Nissen Fundoplication, Used to treat GERD. Fundus of stomach is wrapped around lower esophagus, laparoscopic vs open.Caution with bougie due to esophageal perforation risk
• Strabismus/Esophoria/Exophoria (eye deviation), Esotropia (inward eye deviation of both eyes), high incidence of PONV so treat with IVF or Zofran, Oculocardiac reflex, trigeminovagal reflex= bradycardia with pressure applied to eye

Test your knowledge on the essential principles of pediatric anesthesia with this quiz. It covers key topics such as preoperative evaluation, induction methods, emergency medications, and NPO guidelines. Perfect for medical students and practitioners looking to refresh their understanding of pediatric anesthesia practices.